Medicare AdvantageCoverageMedium impact
MA08.161d, Retifanlimab-dlwr (Zynyz®)
Independence Blue Cross·Oncology, Pharmacy, General Surgery·Pharmacy
Effective date
May 4, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross Medicare Advantage added appendiceal neoplasms as a new covered indication for retifanlimab-dlwr (Zynyz) and revised coverage criteria for anal carcinoma and colon cancer, effective May 4, 2026. Billing teams must update claim submission protocols to reflect expanded coverage for this PD-1 inhibitor immunotherapy across multiple cancer types with specific medical necessity requirements.
Action Required
By May 4, 2026: Billing team must update claim submission system to recognize retifanlimab-dlwr (J9345) coverage for the newly added appendiceal neoplasms indication and revised criteria for anal carcinoma and colon cancer. Implement pre-claim verification checks to ensure: (1) diagnosis codes match covered indications; (2) for appendiceal neoplasms—verify dMMR/MSI-H or POLE/POLD1 mutation status with TMB >50 mut/Mb; (3) for anal carcinoma second-line—confirm no prior immunotherapy; (4) for first-line anal carcinoma—confirm combination therapy with carboplatin and paclitaxel. Update clinical documentation templates and prior authorization workflows to require oncology providers to document molecular testing results and treatment history. Claims submitted without proper documentation of genetic/molecular markers or immunotherapy history will be denied. Notify oncology and surgical practices of expanded coverage.